Exam (elaborations)
Comprehensive Exam A-Evolve hesi 100Questions and Answers (Latest Update 2024/2025)RATED A+
- Course
- Institution
Comprehensive Exam A-Evolve hesi 100Questions and Answers (Latest Update 2024/2025)RATED A+
[Show more]
Content preview
Comprehensive Exam A-Evolve hesi100Questions and Answers (Latest Update
2024/2025)RATED A+
A nurse who has recently completed orientation is beginning work in the labor and
delivery unit for the first time. When making assignments, which client should the
charge nurse assign to this new nurse?
A.A primigravida who is 8 cm dilated after 14 hours of labor
B.A client scheduled for a repeat cesarean birth at 38 weeks' gestation
C.A client being induced for fetal demise at 20 weeks' gestation
D.A multiparous client who is dilated 5 cm and 50% effaced - CORRECT ANSWERS
D
The new nurse should be assigned the least complicated client to gain experience
and confidence, as well as protect client safety. Of the clients available for
assignment, (D) is progressing well and is the least complicated. (A, B and C) have
actual or potential complications and should be assigned to a more experienced
nurse.
A client with human immunodeficiency virus (HIV) infection has white lesions in the
oral cavity that resemble milk curds. Nystatin (Mycostatin) preparation is prescribed
as a swish and swallow. Which information is most important for the nurse to
provide the client?
A.Oral hygiene should be performed before the medication. B.Antifungal
medications are available in tablet, suppository, and liquid forms.
C.Candida albicans is the organism that causes the white lesions in the mouth.
D.The dietary intake of dairy and spicy foods should be limited. - CORRECT
ANSWERS A
HIV infection causes depression of cell-mediated immunity that allows an
overgrowth of Candida albicans (oral moniliasis), which appears as white, cheesy
plaque or lesions that resemble milk curds. To ensure effective contact of the
medication with the oral lesions, oral liquids should be consumed and oral hygiene
performed before swishing the liquid Mycostatin (A). (B and C) provide the client
with additional information about the pathogenesis and treatment of opportunistic
infections, but (A) allows the client to participate in self-care of the oral infection.
Dietary restriction of spicy foods reduces discomfort associated with stomatitis, but
restriction of dairy products is not indicated (D).
,Comprehensive Exam A-Evolve hesi
100Questions and Answers (Latest Update
2024/2025)RATED A+
A client who is admitted with emphysema is having difficulty breathing. In which
position should the nurse place the client?
A.High Fowler's position without a pillow behind the head
B.Semi-Fowler's position with a single pillow behind the head
C.Right side-lying position with the head of the bed elevated 45 degrees
D.Sitting upright and forward with both arms supported on an over the bed table -
CORRECT ANSWERS D
Adequate lung expansion is dependent on deep breaths that allow the respiratory
muscles to increase the longitudinal and anterior-posterior size of the thoracic cage.
Sitting upright and leaning forward with the arms supported on an over the bed
table (D) allows the thoracic cage to expand in all four directions and reduces
dyspnea. A high Fowler's position does not allow maximum expansion of the
posterior lobes of the lungs (A). A semi-Fowler's position restricts expansion of the
anterior-posterior diameter of the thoracic cage (B). Positioning a client on the right
side with the head of the bed elevated (C) does not facilitate lung expansion.
A client with chronic renal insufficiency (CRI) is taking 25 mg of hydrochlorothiazide
(HCTZ) PO and 40 mg of furosemide (Lasix) PO daily. Today, at a routine clinic visit,
the client's serum potassium level is 4 mEq/L. What is the most likely cause of this
client's potassium level?
A.The client is noncompliant with his medications.
B.The client recently consumed large quantities of pears or nuts.
C.The client's renal function has affected his potassium level.
D.The client needs to be started on a potassium supplement. - CORRECT
ANSWERS C
The client has a normalized potassium level despite diuretic use (C). The kidney
automatically secretes 90% of potassium consumed, but in chronic renal
insufficiency (CRI), less potassium is excreted than normal. Therefore, the two
potassium-wasting drugs, a thiazide diuretic and loop diuretic, are not likely to
affect potassium levels. The normal potassium level is 3.5 to 5 mEq/L, and with a
potassium level of 4 mEq/L, there is no reason to believe that the client is
,Comprehensive Exam A-Evolve hesi
100Questions and Answers (Latest Update
2024/2025)RATED A+
noncompliant with his treatment (A). Pears and nuts do not affect the serum
potassium level (B). There is no need for a potassium supplement (D) because the
client's potassium level is within the normal range.
A registered nurse (RN) delivers telehealth services to clients via electronic
communication. Which nursing action creates the greatest risk for professional
liability and has the potential for a malpractice lawsuit?
A.Participating in telephone consultations with clients
B.Identifying oneself by name and title to clients in telehealth communications
C.Sending medical records to health care providers via the Internet
D.Answering a client-initiated health question via electronic mail - CORRECT
ANSWERS C
Sending medical records over the Internet, even with the latest security protection,
creates the greatest risk for liability because of the high potential of breaching
client confidentiality and the amount of information being transferred (C). Client
confidentiality is protected by federal wiretapping laws making telephone
consultation (A) a private and protected form of communication. By stating one's
name and credentials in telehealth communication (B), one is taking responsibility
for the encounter. E-mail initiated by the client (D) poses less risk than sending
records via the Internet.
Which pathophysiologic response supports the contraindication for opioids, such as
morphine, in clients with increased intracranial pressure (ICP)?
A.Sedation produced by opioids is a result of a prolonged half-life when the ICP is
elevated.
B.Higher doses of opioids are required when cerebral blood flow is reduced by an
elevated ICP.
C.Dysphoria from opioids contributes to altered levels of consciousness with an
elevated ICP.
D.Opioids suppress respirations, which increases Pco2 and contributes to an
elevated ICP. - CORRECT ANSWERS D
, Comprehensive Exam A-Evolve hesi
100Questions and Answers (Latest Update
2024/2025)RATED A+
The greatest risk associated with opioids such as morphine (D) is respiratory
depression that causes an increase in Pco2, which increases ICP and masks the
early signs of intracranial bleeding in head injury. (A, B, and C) do not support the
risks associated with opioid use in a client with increased ICP.
The charge nurse of a medical surgical unit is alerted to an impending disaster
requiring implementation of the hospital's disaster plan. Specific facts about the
nature of this disaster are not yet known. Which instruction should the charge nurse
give to the other staff members at this time?
A.Prepare to evacuate the unit, starting with the bedridden clients.
B.UAPs should report to the emergency center to handle transports.
C.The licensed staff should begin counting wheelchairs and IV poles on the unit.
D.Continue with current assignments until more instructions are received. -
CORRECT ANSWERS D
When faced with an impending disaster, hospital personnel may be alerted but
should continue with current client care assignments until further instructions are
received (D). Evacuation is typically a response of last resort that begins with clients
who are most able to ambulate (A). (B) is premature and is likely to increase the
chaos if incoming casualties are anticipated. (C) is poor utilization of personnel.
The nurse assesses a client while the UAP measures the client's vital signs. The
client's vital signs change suddenly, and the nurse determines that the client's
condition is worsening. The nurse is unsure of the client's resuscitative status and
needs to check the client's medical record for any advanced directives. Which action
should the nurse implement?
A.Ask the UAP to check for the advanced directive while the nurse completes the
assessment.
B.Assign the UAP to complete the assessment while the nurse checks for the
advanced directive.
C.Check the medical record for the advanced directive and then complete the client
assessment.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller ACADEMICNURSING001. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $17.39. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
75759 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now